7144 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
'AUDRE55 '
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ' 7144
OWN PLAN CHECK VALIDATION
NAME
- V. ELECTRIC PERMIT FEE
PRONE
CONsyr�� NAME nC UTLETS-SWITCHES-RECEP 5.00/1.00
C LIGHTING FIXTURES. 5.00/1.00
o PPLIANCES-RESIDENTIAL `4.00
ADDc
ADW Es + '
C L � HON PANELS 5.00 DATE OF APPLICATION
ARC ITT SIGNS .(j,00 'PLAN CHECK FEE P.C.NO.
OR
ENGINEER'
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG SPECIAL CIRCUIT '5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS '^ SEE FEE SCH. •,
ADDRESS
' SERVICE CHANGE � � 10.00 r
ww o .LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE UATE
so< u (commencing with Section 7000)of Division 3 of the Basincusav,164 BLDG. ELECT. MECH.
r i Professions Code,and my licensees in full fore ❑ ❑ ❑
z O{Ai+- Lic nse a•;a Lic.Number
Q ro role., Da Contractor'
s ( V ul� BUILDIN PERMIT
irw OWNER-BUILDER DECLARA INFORMATION
r^ p
W O n I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 0,,+ VALUATION '
F,.w j y city"or law for the following reason.(Sec.707 Lsi
5,Buness a '$/FT.
nd Professions PERMIT ISSUANCE 6,00
Code:Ancounty which requires a permit to construct,alter, -
reQ Q p improve.demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEG a
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
rl w m he is licensed pursuant to the provisions of the Contractor's License /
r i i Law(Chapter 9(commencing with Section 7000 ot'Division 3 oflhe
a Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBINGPERMIT FEE
ic I $' the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&,VENT-WATER IEA.14.00
of not more than five hundred'dollars(55000.):
❑ I,as..net of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE '2.00 oce.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure is not.
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of,
-�` R property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
_ \P himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year ofcompletion,the Owner-
S
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
RESIND CON PB Other
V_P prove for purpose of sale.), INDUSTRIAL WASTE INTER. 20.00
- ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
'licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
' to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
can tracts for such projects with a cnntractorl s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
their cis for
License Law.
❑ I am exempt under See. ,BARC.for this WATER HEATER W/VENT 4.00
reason
Owncr Dale WATER SYSTEM , 4.00 'ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a rertific c o consent l+ sell'-insure, ZONING ENG.SITE NO.
JApfic
of Worke Compa s ra c a ec'u'le C.)m I y� i h e i' 'd. FIRE SPRINK ENERGY TQ4
2 is fi D h 't n d e o _,O MISC. REFER TO ORD, r❑ N❑ r❑ N❑PERMIT ISSUANCE 6.00 FLOOD ZONE' A.L.U.C.
CATEOF.I ATIO1'INS FROM WORKERS'IL >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.CL 0 need not he completed if the permit is for one TOTA kr Y❑ N❑ r❑ NO
D Z hundred dollars(S 100)or less.) - "
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
I LL H mit is issued.I shall not employ any person in any manner so as to
U become subject in the Workers Compensation Laws of California.
m Date . Applicant ALTER OR ADD TO MECH. 4.00 BUILDING '
} to NOTICE 'TO APPLICANT: IL after making this Certificate of Ex-
F. ? emption,you should become Subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000GEM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 '
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CIv.L'.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
Ordinances and state laws relating to building construction, and
hereby authorize repecsenmtives of this city to enter upon the BOILER-COMP (Over t00,OOOBTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
in any way acc a against Said City I'M onsequence of the
ra lft If this p n H.CONT. LIC.NO. MECH. /
hl NOTAL TOTAL IL
i toe t Ap c 'on actor ate '
OFFICECOPY �'